Background
Globally, there has been tremendous progress in reducing child mortality. A recent report by the United Nations Inter-agency Group for Child Mortality Estimation (UN-IGME) indicates that the total number of under-five child deaths dropped from 12.6 million in 1990 to 5.6 million in 2016, with the under-five child mortality rate having declined by 56%, from 93 to 41 deaths per 1000 live births [
1]. Nonetheless, wide differentials exist in child mortality between and within countries. Reducing inequities and reaching the most vulnerable children (and their mothers) are important priorities to achieve the Sustainable Development Goals targets on ending preventable child deaths by 2030 [
2].
Health indicators are on average better in urban than rural areas [
3‐
6]. In Malawi, for example, under-five child mortality rate was 130 compared to 113 deaths per 1000 live births for rural and urban residents, respectively, in 2010 [
7], and 77 and 60 deaths per 1000 live births for rural and urban residents in 2015 [
8]. Other child health indicators generally reflect this trend of an urban advantage in many developing countries [
3‐
6].
An analysis of under-five child mortality data in resource-poor settings noted a declining trend of child mortality in many countries, mostly with an urban advantage. Evidently, in the period between 1950 and 2000, under-five child mortality is said to have declined by 57% in both urban and rural areas [
9]. However, over the same period, urban mortality patterns in Africa, Asia, and Latin America were reported to be 25% lower than rural mortality albeit acknowledging country variations in the urban-rural divide [
9,
10].
Historically, prior to and in the early stages of industrialization, health indicators in urban areas of many countries in Europe were worse off than in rural areas. For example, evidence suggests that in the nineteenth century, infant mortality in urban areas in England and Wales were 2.2 times higher than in rural areas [
9,
10]. With prevailing circumstances as these at the time, some authors have argued that the urban population could easily have been wiped out if it were not for high levels of in-migration [
10].
The term
urban penalty was prompted due to the phenomenon of worse health status of urban residents [
11‐
13]. However, over the years, the public health revolution characterized by improved sanitation, access to safe water, vaccinations, and improved housing conditions led to improvements in urban health indicators to the extent that they became better than in rural areas. This health transition has gone on for a few decades, and the urban areas have enjoyed a health advantage over the rural areas leading to a phenomenon that has been termed the
urban advantage [
8,
14,
15].
Nonetheless, for about three decades now, since the urban health discourse has received some prominence in global health, some authors have argued that aggregate urban-rural comparisons suggesting an urban advantage are misleading considering that the urban population is not homogeneous [
6,
12,
14‐
17]. Moreover, literature discourse has suggested that some population groups in urban areas, particularly those residing in urban slums, face similar levels of health disadvantage or in some cases actually face worse health outcomes than the rural areas [
6,
12,
15‐
19]. In essence, poor health indicators in urban slums have been cited among reasons for the stagnating improvements in aggregate urban health indicators in some countries.
In recent decades, the world population has increasingly become urban based. The United Nations estimated that in 2016, about 55% of the world population were in urban settlements, and projected that this will increase to 60% by 2030. It is projected that most of the urban population growth will be occurring in least developed countries and that urban population will grow by 63% between 2015 and 2030 [
20]. Four main reasons are cited as global determinants of increasing urbanization rates. These include (i) natural growth, whereby the existing urban population grows as a result of a high rate of natural increase (i.e., the difference between crude death rate and crude birth rate), (ii) internal rural-to-urban migration, (iii) international urban migration which relates to people moving from urban areas from one country to the other, and (iv) reclassification of urban boundaries encompassing formerly rural areas thereby increasing the urban population count by new geographical demarcations [
21].
Malawi’s population of about 17.3 million in 2017 is predominantly rural based with only about 15% of the population residing in urban areas [
22]. Different figures have been provided for Malawi’s urbanization rate from 4% [
23] to as high as 6.2% which makes it among the highest in the world [
24]. In Malawi, natural growth and rural to urban migration are arguably two main reasons attributable to the high urbanization rate. Evidently, there is a high total fertility rate of 4 among urban women in Malawi [
7] and rural to urban migration accounts for 54% of total migration [
25]. People migrate from rural to urban areas due to,
inter alia, limited cultivable land in rural areas, lack of rural off-farm economic activities, environmental degradation resulting in inability to perform some of the conventional livelihood activities, and escaping rural poverty and the perception of a better life in the cities [
26].
Poverty levels remain high with 74% of households in Malawi considering themselves poor [
27]. In urban areas, this has led to emergence of urban slums characterized by inadequate access to clean water, sanitation, overcrowding, insecurity of housing tenure, and inadequate access to health and other social services [
24,
28,
29], all of which are critical determinants of health. Indeed, the UN-HABITAT estimates that 61% of the urban population in Lilongwe, Malawi’s capital city, resides in slum conditions [
24].
In view of the aforementioned evidence and context, the key question for public health in the urban setting, therefore, is whether there is any evidence of a declining urban advantage. This paper seeks to contribute to this area of urban health discourse, using under-five child health indicators as reported in five Demographic and Health Surveys (DHS) and two Multiple Indicator Cluster Surveys (MICS) in Malawi.
Discussion
This study sought to explore whether the urban advantage in child health indicators is declining in Malawi. The results show that all forms of child mortality have significantly declined between 1992 and 2015/2016 reflecting successes in child health interventions. Rural–urban comparisons, using rate differences, largely indicate a picture of the narrowing gap between the two geographical areas albeit the extent and pattern are different at the levels of child mortality, morbidity, and health service use.
Of the 13 child health indicators used in this study, eight (NMR, IMR, U-5MR, stunting rate, proportion of children treated for diarrhea and fever, proportion of children sleeping under ITN, and children fully immunized at 12 months) show clear patterns of a declining urban advantage particularly up to 2014. However, U-5MR shows a reversal to a significant urban advantage in 2015/2016, and slight increases in urban advantage are noticed for IMR, underweight, full childhood immunization, and stunting rate in 2015/2016.
Furthermore, of the eight, five (NMR, IMR, diarrhea treatment, fever treatment, and full immunization coverage) reach a point of reversal where one or more data points show a move from an urban to a rural advantage position. Four indicators (prevalence of fever, ARI, diarrhea, and treatment of ARI) have shown fluctuating trends with a declining urban advantage largely moving from 2000, 2004, to 2010 data points before another increase in 2014, except for ARI treatment which shows an unstable trend across all data points. Prevalence of underweight is the exception as it starts from a rural advantage when the data was first available in 2000 before a reversal to a slight urban advantage in 2006 MICS moving to almost equal levels in 2010 and a slight urban advantage in the 2015/2016 survey report.
A notably consistent decline in urban advantage with regard to all forms of childhood mortality is mainly due to a more rapid absolute decline in childhood mortality in rural areas. For health service-related indicators that show a declining urban advantage as aforementioned, it is seemingly due to two main reasons: (i) higher absolute increase in utilization of child health services in the rural areas, and (ii) lower absolute decrease in the rate of utilization of child health services in rural areas where the pattern in both urban and rural showed low utilization relative to the preceding survey. In some few cases, the narrowing gap between urban and rural is due to worsening of the indicator between one data point and another in the urban while there is an improvement between the same data points in the rural area. For example, while IMR increased in urban areas from 60 deaths per 1000 live births in 2004 to 70, 73, and 61 in the 2006, 2010, and 2014 reports, respectively, it largely reduced in rural areas over the same period from 98 to 73, 73, and 52 deaths per 1000 live births. Conversely, the increasing urban advantage typically noticed for some indicators in 2015/2016 is because of a faster improvement of respective child health indicators in urban areas and not necessarily worsening of indicators in rural areas.
Our findings suggest that for most indicators, a clear trend of declining urban advantage emerged for a large part of the years under review. This is consistent with other studies in Africa which have largely demonstrated the narrowing urban–rural gap with regard to child mortality and other determinants of childhood morbidity and mortality. Evidently, Garenne investigated trends in urban and rural mortality by reconstructing yearly mortality estimates from Welfare Monitoring Surveys (WMS) and DHS data from some sub-Saharan African countries which included Malawi in the periods from early 1970s to the late 1990s. The results, while generally affirming the declining trend in child mortality in both urban and rural settings, indicated that in some countries such as Burkina Faso, Rwanda, Senegal, Togo, and Uganda, mortality decline was faster in rural areas effectively narrowing the rural–urban gap. In Benin, urban mortality had stagnated while it continued declining in rural areas also reducing the rural–urban gap. In cases where the rural–urban gap had increased due to a faster mortality decline in urban areas such as Niger and Mozambique, the situation was reversed with data of the late 1990s [
9]. Likewise, Murage et al. found that while there was an overall decline in childhood mortality in Kenya, urban–rural gaps in mortality narrowed and that mortality levels in urban slums showed a declining trend but remained high [
19].
Furthermore, similar to our study, an analysis was conducted using DHS data to determine trends in urban–rural differentials of malnutrition among children aged 1 to 35 months for 15 sub-Saharan African countries. The results indicate a general decline in urban advantage in 8 of the 15 countries albeit with statistical significance in only two of these, no change in urban–rural differentials in four countries, and an increasing urban–rural gap in three of the countries. An increase in urban malnutrition was attributable to the declining urban advantage in some countries whereas a faster declining rate of urban malnutrition was responsible for the widening urban–rural gap in others [
14].
On the basis of evidence from our descriptive study, it is clear that while there are some fluctuating patterns in some indicators, a trend of declining urban health advantage in so far as child health indicators are concerned in Malawi appears evident over the years. The underlying factors for this phenomenon are not obvious from the current study, but various hypotheses can be put forward for further interrogation in the context of Malawi but which have been highlighted in literature.
We postulate that the three salient factors proposed by Garenne and to some extent supported by other authors [
14‐
19] as being responsible for the narrowing urban–rural gaps in health are applicable in Malawi. These factors, in aggregate terms, relate to determinants of urban health, and they include extreme urban poverty in some areas of the urban such as the urban slums often due to lack of state interventions; emerging diseases such as HIV and AIDS for which there is a greater disease burden in the urban than rural areas, especially in the pre-ART (anti-retroviral therapy, including prevention of mother-to-child transmission) era; and heightening risk of some diseases such as respiratory infections resulting from air and chemical pollution in cities.
Indeed, while Malawi is one of the least urbanized countries, its rate of urbanization is high and the majority (up to 61%) of people in Malawi’s capital city are said to be residing in slum conditions which embody urban poverty that manifest in limited access to improved water, appropriate sanitation, durable housing, sufficient living area, and insecurity of tenure [
4]. The HIV factor is relevant granted that the HIV burden in Malawi shows geographic disparities and the urban HIV prevalence is almost twice as high (17.4%) as in rural areas (9%) [
8]. Moreover, AIDS-related mortality accounted for about 13% and was among the top three causes of under-five mortality, and it can logically be argued that this affected the urban more than the rural at some point. The tremendous progress of the prevention of mother-to-child transmission (PMTCT) program in Malawi in recent years is however noted having registered a 71% reduction in mother-to-child transmission rate between 2009 and 2015 [
46]. A successful PMTCT program in Malawi may explain greater survival of infants in the urban areas (which is disproportionately affected by HIV) and ultimately an increasing urban advantage in IMR as reflected in the 2015/2016 DHS report.
The heightened risk of respiratory infections due to air pollution cannot be backed by evidence from this study. In essence, the trend of ARI prevalence in the urban area seems to be that of a declining burden (see Table
2) albeit the cross-sectional nature of the national surveys used in this study is not the most appropriate to provide a true picture even when most surveys were undertaken over the same period of the year. Indeed, all the surveys ask for child morbidity in the 2 weeks preceding day of interview and would not be as precise in measuring a comprehensive morbidity burden as would a prospective study ascertaining incidence of ARI episodes over a given period. This notwithstanding, some underlying causes of child morbidity and mortality such as stunting rates have either stagnated, worsened, or dismally improved in urban areas over long periods and could play a critical role.
Our study has also shown that the urban advantage with regard to child health service use has been waning. In fact, when needed, some health service components such as diarrhea treatment, fever treatment, and childhood immunization have recently reversed from an urban to a rural advantage. In this regard, it would be argued that Malawi Ministry of Health policies of promoting access to health services for the rural population such as using Service Level Agreements, increasing health infrastructure, and undertaking community outreach clinics [
37] may have yielded results. However, the findings also call into question the assumption that urban residents have adequate access to health services by virtue of geographical proximity relative to rural areas and that they ultimately have much better child health outcomes. Moreover, studies have demonstrated that access to health services transcends physical access [
5,
47‐
49]. It is therefore imperative for the Ministry of Health in Malawi to rethink the policy premised on urban advantage pertaining to access to child healthcare services. Community health interventions such as child immunization and community case management of common childhood conditions like diarrhea could be considered especially in impoverished urban areas. Arguably, implementing an integrated Community Case Management (iCCM) component of IMCI in urban slums would be a form of differentiation of child healthcare delivery in the urban setting, effectively affording prompt access to essential child health interventions.
Some authors have argued that a stagnation of urban health levels, due to, among other reasons, the pervasive socioeconomic inequalities, has led to the narrowing of the urban–rural health gap [
50]. Our study does not provide any evidence to this effect. The national surveys in this study do not report further socioeconomic quintile analysis by rural and urban geographical areas albeit it is possible to undertake a secondary analysis of their primary data. This was beyond the scope of this study but represents an area where further analysis is required granted the paucity of evidence of intra-urban child health inequities in Malawi and the effect of urban economic deprivation to overall urban health.
Could the declining urban advantage noted especially up to 2014 in this study merely be a phenomenon of the rural setting catching up with the urban? This is unlikely to be the case granted that the levels of child mortality and morbidity in urban areas also remain high and health service use is suboptimal, hence having more room for improvements at a rate similar to that in the rural areas or even better. Moreover, an increasing urban advantage in some child health indicators in the recent 2015/2016 DHS in the context of faster absolute improvements in urban relative to rural supports the assertion that there is still room for significant improvements in child health indicators in both settings.
We note some limitations to our study that should be taken into consideration when interpreting our results. We relied on already estimated values in DHS and MICS; hence, the limitations of these surveys such as recall bias and reporting bias should be borne in mind. The rigor in undertaking both DHS and MICS surveys used in this study and the fact that they are the most frequently used in shaping policy represent particular strengths.